AIRWAY - BREATHING - HABITS AIRWAY - BREATHING - HABITS - - PowerPoint PPT Presentation

Jules E. Lemay III

d.d.s., cert. ortho., F.R.C.D. (C) Diplomate, American Board of Orthodontics

AIRWAY - BREATHING - HABITS & MYOFUNCTIONAL CONSIDERATIONS in ORTHODONTICS AIRWAY - BREATHING - HABITS & MYOFUNCTIONAL CONSIDERATIONS in ORTHODONTICS

ORAL HABITS ORAL HABITS

  TONGUE THRUSTING

TONGUE THRUSTING

  DIGIT SUCKING

DIGIT SUCKING

  TONGUE SUCKING

TONGUE SUCKING

  NAIL & LIP BITING

NAIL & LIP BITING

  foreign objects

foreign objects

✓

2

Most prevalent habit in children (50%)

• Tongue thrust
• Pursed lips
• Peri-oral sphincter action
• Mand. thrust
• Tongue:

♦ away from palate ♦ narrow, elongated ♦ depressed central furrow

• Peri-oral sphincter action
• Separated gum pads

3..

Infantile (Visceral) Swallow

• Peri-oral sphincter action
• No mand. thrust
• Momentary inc. contact
• Tongue:

♦ humped up ♦ approximates palate ♦ shallow central furrow ♦ peristaltic action ♦ border between teeth

Mature (Somatic) Swallow Mature (Somatic) Swallow

4

  SYNONYMS:

SYNONYMS:

  NORMAL,

NORMAL, MATURE, SOMATIC SWALLOW MATURE, SOMATIC SWALLOW

  FACTS:

FACTS:

  MAY APPEAR AS EARLY AS AGE 3

MAY APPEAR AS EARLY AS AGE 3

  CONSIDERED

CONSIDERED NORMAL NORMAL BY BY AGE 4-5 AGE 4-5

  ACHIEVED BY

ACHIEVED BY 50% 50% AT AT AGE 6 AGE 6

ADULT SWALLOW

5

 FREQUENCY & DURATION:

FREQUENCY & DURATION:

 

… …

 

FREQUENCY & DURATION FREQUENCY & DURATION

 FREQUENCY: Estimates = 1200-2400x / day  Swallowing: 1x / min. x 1 sec. duration

x 60 min. x 24hr = 1400 sec. / day

 DURATION ≈ 1400 sec. / day = 23-25 min.  Variable (Sleep = 4-8 x / hr)  Reality: 800-1000 sec. / day = 13-16 min.

ADULT SWALLOW

  “

“RETAINED RETAINED” ” INFANTILE SWALLOW INFANTILE SWALLOW

  MISNOMER: THRUSTING

MISNOMER: THRUSTING vs vs FORCE FORCE

  “

“HABIT HABIT” ” vs vs ABNORMALITY ABNORMALITY

  DELAYED LEARNING

DELAYED LEARNING

TONGUE THRUSTING

(terminology )

7

✓

AGE AGE INCIDENCE INCIDENCE

REFERENCE REFERENCE newborn newborn 97.0% 97.0%

LEWIS et AL (1965) LEWIS et AL (1965)

• 10-15

10-15 % % NEVER NEVER ACHIEVE ACHIEVE 10-15 10-15 % % NEVER NEVER ACHIEVE ACHIEVE ADULT ADULT SWALLOW SWALLOW ADULT ADULT SWALLOW SWALLOW

8..

INCIDENCE OF TONGUE THRUSTING INCIDENCE OF TONGUE THRUSTING

1

1 50-70% 50-70%

DAVIDSON (1967) DAVIDSON (1967)

4 4 most have stopped most have stopped

” ” ” ”

4.9

4.9 58-86% 58-86%

HANSON HANSON

5

5 82.0% 82.0%

BELL et AL BELL et AL

6

6 52.3% 52.3%

FLETCHER et AL (1961) FLETCHER et AL (1961)

35-71% 35-71%

HANSON HANSON

50% 50%

8

8 38.0% 38.0%

FLETCHER et AL (1961) FLETCHER et AL (1961)

9 9 41.9% 41.9% ” ” ” ” 10 10 34.0% 34.0%

”

” ” ” 16 16 23.5% 23.5% ” ” ” ” 18 18 24.5% 24.5%

”

” ” ”

10 10 20 20 30 30 40 40 50 50 60 60 6 6 10 10 14 14 18 18 Tongue-thrusters (White) Female Thumbsuckers Male Thumbsuckers Black Children White Children

Open Bite > 2mm

AGE AGE % P O P U L A T I O N % P O P U L A T I O N 9.

Fletcher et al. 1961

Prevalence vs Age Prevalence vs Age

10x 10x

  DURATION

DURATION

  INTENSITY

INTENSITY

  LIGHT

LIGHT vs vs HEAVY PRESSURE HEAVY PRESSURE

  OPEN BITES: 2 X normal tongue pressure

OPEN BITES: 2 X normal tongue pressure

  PROTRUDING INC.: less pressure against incisors

PROTRUDING INC.: less pressure against incisors

  FREQUENCY

FREQUENCY

  T. THRUSTERS SWALLOW LESS OFTEN

• T. THRUSTERS SWALLOW LESS OFTEN

  RESTING POSTURE

RESTING POSTURE

ROLE of the TONGUE in MALOCCLUSION ROLE of the TONGUE in MALOCCLUSION

✓ ✓

10

  T.T. &

T.T. & maloccl

• maloccl. relationship is

. relationship is unclear unclear

(WHITE, 1979 )

(WHITE, 1979 )

  Chronic / persistent T.T.

Chronic / persistent T.T.

  may prevent spontaneous self-correction of a

may prevent spontaneous self-correction of a maloccl

• maloccl. or exacerbate it.

. or exacerbate it. (AAO, 1991)

(AAO, 1991)

  Direct

Direct cause-and-effect relationship is cause-and-effect relationship is questionable questionable (AAO, 1991)

(AAO, 1991)

  T.T. =

T.T. = Contributing Contributing factor factor in the development of malocclusions in the development of malocclusions

TONGUE THRUSTING vs MALOCCLUSION

... SOME CONCLUSIONS

11.

Multifactorial Etiology

✓

GLOSSECTOMY EXPERIMENT

CONCLUSIONS

HARVOLD et AL, 1968

  TONGUE FUNCTION &

TONGUE FUNCTION & POSTURE POSTURE

• greater influence on the
• greater influence on the mand
• mand. arch (stability)

. arch (stability)

  OCCL. & INTERDIGITATION of TEETH

• OCCL. & INTERDIGITATION of TEETH
• minor influence on arch form
• minor influence on arch form

  SHAPE OF THE TONGUE

SHAPE OF THE TONGUE

• adapts to its surroundings
• adapts to its surroundings

12

Resting Pressure: Tongue Resting Pressure: Tongue vs vs Lips Lips

5 gm 5 gm 5 gm 5 gm < 5 gm < 5 gm 10 gm 10 gm

Tongue

13…

PDL metabolic activity

Balanced Forces Balanced Forces Equal Forces Equal Forces

JHL JHL JJ JJ

W.

• W. Proffit

Proffit 2004 2004

« « Goals Goals and and Limitations Limitations of

• f

Orthodontic and Orthognatic Orthodontic and Orthognatic treatments treatments are are determined determined by by the the soft tissues soft tissues of

• f the mouth

the mouth and and face face and and not by not by the teeth the teeth and bones and bones » »

Soft Tissue Paradigm

  RESPIRATORY NEEDS

RESPIRATORY NEEDS

  = Primary determinant of jaw

= Primary determinant of jaw & & tongue posture tongue posture

(CAN ALTER JAW & TONGUE (CAN ALTER JAW & TONGUE POSITION) POSITION)   Newborns =

Newborns = Obligatory nasal breathers

Obligatory nasal breathers

  HUMANS =

HUMANS = Nasal breathers primarily

Nasal breathers primarily

  TOTAL

TOTAL NASAL NASAL OBSTRUCTION OBSTRUCTION

  Very rare in humans

Very rare in humans

  TERMINOLOGY:

TERMINOLOGY: “ “ORONASAL ORONASAL” ” RESPIRATION RESPIRATION

Proffit Proffit Proffit Proffit, , , , 1986

1986 1986 1986

MOUTH BREATHING FACTS MOUTH BREATHING FACTS

15

MOUTH BREATHING: Possible Etiologies MOUTH BREATHING: Possible Etiologies MOUTH BREATHING: Possible Etiologies

  ENLARGED

ENLARGED T & A T & A

  STRUCTURAL

STRUCTURAL NASAL DEFECTS NASAL DEFECTS

  NASAL POLYPS

NASAL POLYPS

  CHRONIC

CHRONIC ALLERGIES ALLERGIES

  INFECTIONS

INFECTIONS

  ASTHMA

ASTHMA

  FOREIGN BODIES

FOREIGN BODIES

  UNREDUCED FRACTURES

UNREDUCED FRACTURES

  AGGRESSIVE SURGICAL

AGGRESSIVE SURGICAL TX TX (cleft palate) (cleft palate) Anything causing obstruction may lead to mouth breathing Anything causing obstruction may lead to mouth breathing

16

  CHANGED MODE OF BREATHING

CHANGED MODE OF BREATHING

GRADUAL: NASAL GRADUAL: NASAL

ORAL

ORAL

  DIFFERENT ADAPTATIONS

DIFFERENT ADAPTATIONS

(individual variation)

(individual variation)

  VARIOUS MALOCCLUSIONS DEVELOPED:

VARIOUS MALOCCLUSIONS DEVELOPED:

CL II-III, OPB, ANT. XB, SPACING, 2-BITES

CL II-III, OPB, ANT. XB, SPACING, 2-BITES

  = ADAPTATIONS / COMPENSATIONS

= ADAPTATIONS / COMPENSATIONS

  PARTIALLY REVERSIBLE

PARTIALLY REVERSIBLE

Effects of M. Breathing Caused by Nasal Obstruction

Effects of M. Breathing Caused by Nasal Obstruction

(Rhesus monkey experiment - (Rhesus monkey experiment - Harvold Harvold et AL., 1973) et AL., 1973) CONCLUSIONS

CONCLUSIONS

17

  IMMUNOLOGY:

IMMUNOLOGY: autovaccination autovaccination

  lymphocytes, antibodies

lymphocytes, antibodies

18.

ROLE of TONSILS & ADENOIDS ROLE of TONSILS & ADENOIDS

  “

“GATE - KEEPERS GATE - KEEPERS” ”: :

  strategic locations

strategic locations

  EARLY

EARLY PROTECTION: PROTECTION:

  1st few weeks of life

1st few weeks of life

  Tonsils vs Adenoids

Tonsils vs Adenoids

  REDUCED NASAL AIRFLOW

REDUCED NASAL AIRFLOW

  STEEPER MAND. PLANE ANGLE

STEEPER MAND. PLANE ANGLE

  MORE RETROGNATHIC MANDIBLES

MORE RETROGNATHIC MANDIBLES

  LONGER ANT. FACIAL HEIGHT

LONGER ANT. FACIAL HEIGHT

  MAX. CONSTRICTION TENDENCY

• MAX. CONSTRICTION TENDENCY

PROFFIT, 1986: PROFFIT, 1986:

  MAX. CONSTRICTION TENDENCY

• MAX. CONSTRICTION TENDENCY

  MORE UPRIGHT INCISORS

MORE UPRIGHT INCISORS

19 19

CHILDREN WITH ENLARGED ADENOIDS CHILDREN WITH ENLARGED ADENOIDS & OBSTRUCTION & OBSTRUCTION

(Linder-Aronson et AL, 1970) (Linder-Aronson et AL, 1970)

  T&A

T&A USED TO BE REMOVED ROUTINELY

USED TO BE REMOVED ROUTINELY

  1980

1980’ ’s: s: STILL VERY COMMON

STILL VERY COMMON

  TREND:

TREND:

  2 x ADENOIDECTOMY ONLY

2 x ADENOIDECTOMY ONLY

  TONSILLECTOMY: SLIGHT INCREASE

TONSILLECTOMY: SLIGHT INCREASE

  2 SEPARATE PROCEDURES

2 SEPARATE PROCEDURES

  RELAPSE:

RELAPSE:

  ADENOIDS: COMMON BEFORE AGE 3

ADENOIDS: COMMON BEFORE AGE 3

  TONSILS: LESS FREQUENT

TONSILS: LESS FREQUENT

20

TONSILLECTOMY & ADENOIDECTOMY

  INFECTIONS

INFECTIONS

  ACUTE & REPETITIVE (T & A)

ACUTE & REPETITIVE (T & A)

  CHRONIC (T & A)

CHRONIC (T & A)

  RECURRENT (middle ear)

RECURRENT (middle ear)

  HYPERTROPHY LEADING TO

HYPERTROPHY LEADING TO OBSTRUCTION OBSTRUCTION

  FUNCTIONAL DISTURBANCES

FUNCTIONAL DISTURBANCES

  SWALLOW

SWALLOW

  SPEECH

SPEECH

  SLEEP - RESPIRATION

SLEEP - RESPIRATION

21

INDICATIONS FOR T&A REMOVAL

  GROWTH PEAK (adenoids): 10-11

GROWTH PEAK (adenoids): 10-11 ➟

➟ 14-15

14-15 yo yo

  PUBERTY: involution of lymphoid tissues

PUBERTY: involution of lymphoid tissues

  REGRESSION: Doesn

REGRESSION: Doesn’ ’t always occur t always occur

  NASOPHARYNX SIZE:

NASOPHARYNX SIZE:

Increase: 150% (1

Increase: 150% (1➟ ➟17y) 17y)

  ADENOID RATE

ADENOID RATE >

> NASOPHARYNX

NASOPHARYNX

Obstruction may disappear

Obstruction may disappear

22

T & A …FACTS

LYMPHOID LYMPHOID NEURAL NEURAL GENERAL GENERAL GENITAL GENITAL MAX. MAX. MAND. MAND. Birth Birth

10 10 20 20

AGE AGE

  FREQUENCY

FREQUENCY

  DURATION (

DURATION (treshold treshold) )

  CHRONOLOGY (age)

CHRONOLOGY (age)

  Deciduous vs Permanent Dent.

Deciduous vs Permanent Dent.

AG AG

Non-Nutrivite Sucking Habits (N-NSH) THUMB SUCKING & DIGIT HABITS

✓ ✓

23

 INTENSITY (force)

INTENSITY (force)

INFANTS INFANTS ± ± 100 % 100 % (natural)

(natural)

0-1 y 0-1 y 50-70 % 50-70 % 3-4.5 y 3-4.5 y 45 % 45 % 4-5 y 4-5 y

SHOULD STOP NATURALLY SHOULD STOP NATURALLY

IF PERSISTS = CHRONIC N-NSH IF PERSISTS = CHRONIC N-NSH

6 y 6 y 13.6 % 13.6 % 11 y 11 y 5.9 % 5.9 %

(females >

(females >

males)

males)

24.

NON-NUTRITIVE SUCKING HABITS NON-NUTRITIVE SUCKING HABITS

(N-NSH)

(N-NSH) PREVALENCE PREVALENCE

Digit Habits (NNSH): Possible Sequellae Digit Habits (NNSH): Possible Sequellae

PRIMARY DENTITION

 Affects mainly the anterior area  Temporary & Reversible

ABH 4.5

✓

CC 3.O CC 3.O

25

 PROLONGED HABITS

PROLONGED HABITS

  Maxillary arch contraction

Maxillary arch contraction

  U. INC.: Spacing, Flaring

• U. INC.: Spacing, Flaring

  L. INC.: Lingual tipping

• L. INC.: Lingual tipping

  Ant. Open Bite & Secondary T.T.

• Ant. Open Bite & Secondary T.T.

DL 16 DL 16 DL 16 DL 16 DL 16 DL 16

Digit Habits (NNSH): Possible Sequellae Digit Habits (NNSH): Possible Sequellae

26

  700 CHILDREN, age 10-12 y

700 CHILDREN, age 10-12 y

  METHOD & DURATION OF FEEDING

METHOD & DURATION OF FEEDING

  TYPE OF NIPPLE USED

TYPE OF NIPPLE USED

  PACIFIER USE

PACIFIER USE

  SUCKING HABITS (thumb / finger)

SUCKING HABITS (thumb / finger)

  HIST. OF ORTHO TX (child & parents)

• HIST. OF ORTHO TX (child & parents)

27 27

BOTTLE FEEDING vs MALOCCLUSION BOTTLE FEEDING vs MALOCCLUSION

(Meyers et Al, 1988) (Meyers et Al, 1988)

Findings: Findings:

  Need for Treatment associated with:

Need for Treatment associated with:

  Bottle feeding (trend)

Bottle feeding (trend)

  Exposure to bottle =

Exposure to bottle = incr

• incr. need for Tx (trend)

. need for Tx (trend)

  Parental

Parental Hx Hx of ortho Tx (genetics): significant

• f ortho Tx (genetics): significant

  No assoc.

No assoc. between method of feeding & N-NSH between method of feeding & N-NSH

  NUK vs other brands:

NUK vs other brands: no proof of a protective effect no proof of a protective effect

Bottle-F. may contribute to malocclusion by: Bottle-F. may contribute to malocclusion by:

  ALTERING

ALTERING

sucking

sucking mcx mcx

growing facial bones

growing facial bones

  CREATING an ABNORMAL SWALLOWING

CREATING an ABNORMAL SWALLOWING PATTERN PATTERN

  INCREASING the PREVALENCE of N-NSH

INCREASING the PREVALENCE of N-NSH

Meyers Meyers et et al, al, 1988 1988 Meyers Meyers et et al, al, 1988 1988 28

  NO

NO DIRECT DIRECT RELATIONSHIP DOCUMENTED RELATIONSHIP DOCUMENTED

  NO SIGNIF. INFLUENCE ON THE INCIDENCE

NO SIGNIF. INFLUENCE ON THE INCIDENCE OF T. THRUSTING OF T. THRUSTING

  BREAST-FEEDING ADVANTAGES:

BREAST-FEEDING ADVANTAGES:

  GREATER

GREATER

• O. MUSCULATURE
• O. MUSCULATURE

EXERCISE EXERCISE

  REQUIRES 60 X MORE ENERGY

REQUIRES 60 X MORE ENERGY

  DIGASTRIC

DIGASTRIC = 2 X STRONGER = 2 X STRONGER

  CONSTANT PULLING = MAND. GROWTH

CONSTANT PULLING = MAND. GROWTH

Westover Westover et et al, al, 1988 1988 29

FEEDING METHODS vs ORAL DEVELOPMENT FEEDING METHODS vs ORAL DEVELOPMENT

(breast (breast vs

vs bottle-feeding)

bottle-feeding)